Abstract

The number of older adults with end stage renal failure is rapidly increasing. Over the last 30 years, attitudes, technologies, resources and the premorbid health status of older adults have evolved and dialysis is now being offered routinely to this group. Dialysis is a life maintaining treatment but is demanding physically and psychologically and these burdens interplay with the normal consequences of aging. To ensure length of life is not preserved at the expense of quality requires focus on the interactions of end stage renal disease (ESRD), renal replacement therapy (RRT) and ageing-related problems, such as immobility and falls. However, despite these considerations being specifically referenced in national policy and recognised amongst dialysis groups internationally, there is limited literature regarding the specific and specialised needs of this patient group or guidance on focussed service development within the United Kingdom.

This work describes the extent and impact of the problems at a local level, explores the depth and impact of these concerns for patients and staff. An extensive literature review was performed. The changing demographics of the renal patient population are described and current services set in the context of local and national planning and policy. The topics of kidney physiology, renal disease, physical fitness, falls, bone metabolism and rehabilitation in non-uraemic and dialysed older adults were studied.

To respond to the patients’ reports and falls events, a study was proposed to assess measures of postural stability before and after a single haemodialysis session in older adults on maintenance haemodialysis. A small-scale exploratory study and feasibility pilot was problematic and prompted review of the research plans. Preliminary data must be interpreted with caution, but suggested that older haemodialysis patients might be weaker and less posturally stable than comparable non-dialysed older adults but that there was no significant effect of a haemodialysis session on the parameters measured. Reports of this initial study have been published in a peer-reviewed journal and presented locally and internationally.

To evaluate fitness limitations from the patients’ perspective, a questionnaire study was administered to 66 older adult maintenance haemodialysis patients and 66 non-uraemic controls. The study revealed higher levels of inactivity, immobility, and dependency, less positive perception of life quality, lower mood, and fewer leisure and pleasure activities in the dialysis group. However, it did not reveal a significantly different falls incidence. This work is being prepared for publication.

A third original project examined staff perceptions of patient fitness and exercise encouragement practices within our local unit. This demonstrated that staff members know of the benefits of encouraging exercise, accept it as part of their role and responsibility and want to promote exercise. Many are already doing so. However, some staff members lack knowledge and confidence. It is encouraging that staff members feel that patients are able and keen to improve their physical fitness and that they would take part in structured programs with regular encouragement and feedback. This work is submitted for national poster presentation and is being prepared for publication.

The optimum design and implementation of exercise regimens for older haemodialysis patients is debated. The thesis concludes with a discussion of the findings and the implications both for service development and for future research. At the time of submission, a project scoping group is meeting to discuss the introduction of a lifestyle program involving exercise interventions, as recommended in this thesis, with the original data supporting a case of need. This group will seek finding for an exercise and lifestyle intervention project through the East Midlands Regional Innovation Fund.